Pregnancy, Delivery INTRODUCTION Background: There are few events that cause an Emergency Physician to sweat; one of the foremost of these is a gravid, term female showing up in the ED ready to deliver. Pathophysiology: It must be kept in mind that pregnancy and delivery are natural processes which have been occurring for millennia. It is only in the relatively recent past that physicians have become involved. Therefore, attendance to the natural course is mandatory; interventions are indicated only with deviations from the natural/expected course. Remember, normal pregnancy is not a disease; it requires no "treatment." Frequency: In the U.S.: The precise incidence of ED deliveries of pregnant term patients is unknown. In 1995, there were 14.8 births/1000 total population. Fertility rates (births/1000 women ages 15 - 44) fell to 65.6. 81.2% received prenatal care in the first trimester. Mortality/Morbidity: The infant death rate for 1995 was 7.5 per 1000 live births. The maternal death rate in 1977 was 9.4/100,000 births (37.1 in 1960.) Of these, some 25% were birth related. Race: There are racial differences in receipt of prenatal care and, thus, in probability of presenting to the ED for care. In 1994, 80% of all mothers initiated care in the first trimester. Cuban mothers reached 90% with Japanese mothers close behind at 89%. Mothers with the lowest percent initiating early prenatal care were non-Hispanic black (68%), Puerto Rican (67%) and American Indian mother (65%). Age: Although fertility rates use 15-year-olds as the lower cutoff, this author believes any female who has reached the age of reproductive ability (potentially as low as 9 - 11 years) and presents with abdominal complaints and an exam which cannot rule out pregnancy should have pregnancy ruled out by laboratory testing. CLINICAL History: History will often be enough to raise the suspicion of pregnancy as the cause of a patient's complaints. However, bear in mind that truly virginal patients can be pregnant and denial of the pregnant state is not uncommon. Symptoms include the following: cessation of menses, morning sickness, urinary frequency, breast enlargement/engorgement, abdominal enlargement, quickening and lightening. Signs include the following: uterine consistency changes (Goodell's and Hegar's signs), mucosal changes (Chadwick's sign), uterine enlargement, change in uterine shape, uterine contractions, breast changes and abdominal examination changes. Pregnancy: Gestation is defined as 280 days. Estimated Date of Confinement (EDC), or due date, is calculated by taking the first day of the last normal menstrual period (FDLMP), adding 3 months and subtracting one week. There are also many hand-held wheels that will do this calculation for you. Claims of regular menstrual periods and/or lack of sexual involvement in no way rules out pregnancy. Labor: Labor may present classically or with many variations. Typically, lightening (settling of the infant, head down, into the true pelvis) will occur several weeks before labor. Braxton-Hicks contractions (irregular rhythmic uterine tightening) may occur. The onset of these contractions is earlier with each succeeding pregnancy. The cervix will efface (thin). Delivery: Onset of true labor may be gradual, abrupt or catastrophic. Regular uterine contractions will cause the cervix to dilate (stage 1.) Descent of the presenting part and delivery make up the second stage. The third stage of labor is delivery of the placenta. For a patient presenting in labor, the following is a minimal data set: LMP/EDC Pregnancy history (gravida, para, X-X-X-X) Gravida = total number of pregnancies (inc. this one) Para = number of deliveries after 20 weeks of pregnancy X-X-X-X = # of term infants - preterm infants - abortions - number of children currently living Prenatal care (including plans for delivery) Problems during pregnancy (this one or prior) Past medical/surgical history Medications Allergies Physical: Physical examination of the abdomen and pelvis is an invaluable tool to diagnosing labor as the cause of a woman's abdominal complaints. Inspection: Abdominal striae may be noted. They are due to the rapid expansion of the uterus. When seated, the epigastrium takes on a typical shelf-like appearance created by lightening. Fetal movements may be appreciated. Percussion: A dullness from the pubic symphysis to several centimeters below the xiphoid is supportive evidence of a term pregnancy (in the right setting). Auscultation: Careful listening with a standard stethoscope (fetal stethoscopes or Doppler probes are nice but unnecessary at term) may reveal fetal cardiac activity. Listening in all four quadrants may demonstrate twins. Palpation: Carefully done, Leopold's maneuvers will tell much information and prepare you for complications. Palpate fundus; smooth, hard, round = head. Irregular = some other part. Palpate sides: smooth, long = back; irregular = front/side. Grasp the part in the pelvis; smooth, hard, round = head. Irregular = some other part. Rub hand along back and down to the pelvis, if it contains the head. A shelf/abrupt change in the angle of the palpated part when the head is encountered = head in extension (face presentation; unfavorable.) A smooth path = head flexed, favorable. Causes: Causes of pregnancy are both obvious (sexual activity) and hidden (lack of access to reliable birth control, poor self-esteem, denial, poverty, etc.) Presentation at the Emergency Department for unplanned delivery has similar risks. Additionally, should the onset of labor be catastrophic (e.g., bleeding, prolapsed cord, footling presentation, etc.), patients may seek care where they have learned it is available fast, hot and now. WORKUP Lab Studies: Few lab tests are of much use. Knowledge of the patient's hemoglobin level and Rh status is all that is initially required. If there has been prenatal care, other lab tests will have been performed. Kleihauer-Betke testing can be ordered after delivery for Rh-negative mothers of Rh-positive infants. (One unit of Rh-immunoglobin/15 ml fetal blood found in the mother's circulation is administered IM within 72 hours of delivery.) Imaging Studies: Generally, if there is time for imaging studies, there is time to get the patient to the OB ward. However, consideration may be given to the following: Ultrasound may be used to determine the following: fetal position, number and/or age, presence of cardiac activity, placental position, complications (abruption), fetal malformation (CNS, developmental, etc.), quantity of amniotic fluid, fetal weight estimation, hydatiform mole and Rh isoimmunization. The Ultrasound has the drawback of not being immediately available at most facilities. Additionally, many emergency physicians are not skilled at interpretation of ultrasonically generated images. Radiography has its place in the emergency assessment of the pregnant patient. It is quickly available at most facilities and emergency physicians are skilled at independent interpretation. As with any test, x-ray studies should be ordered only when clearly needed. If areas other than the pelvis require radiographs, shield the abdomen; x-ray the abdomen only when absolutely needed. Plain films of the abdomen may be used for both pelvimetry and the fetal position and number. TREATMENT Prehospital Care: Routine EMS protocols will suffice in general. Apply O2. Obtain IV access. Generally transport in the left lateral recumbent position; use this position especially if the expectant mother's blood pressure falls (from pressure on the vena cava, reducing return to the heart.) Prepare expectantly for field delivery as there is little that can be done to prevent birth. Emergency Department Care: There will be little time for the niceties such as a fetal monitor. Once again, if there is time to obtain and attach a fetal monitor, there is time to get the mother to OB. That said, one should take a brief history (above) and perform a brief, directed physical, making an effort to auscultate the fetal heart activity. (If the baby is crowning, there won't be time for this.) If the baby is not yet crowning (child's head bulging the perineum), a brief, sterile gloved vaginal exam will tell you if the cervix is dilated (up to 10 cm) and/or effaced (thinned to just about 1 mm) Additionally, determine the descent of the presenting part relative to the ischial spines (in cm, expressed as + when caudal to the spines.) At this time, determine the identity of the presenting part. Smooth, with a Y configuration is the best; this is the lambdoid suture, indicating a head that is flexed. A + configuration is the bregmoid suture; this is not as good (but may give you time to get the patient to OB.) Face, foot/feet, hand/arm and breech will be obvious on palpation. These can be quite problematic to deliver in the ED and generally require special expertise. If the baby is not crowning, the mother is not yet complete (or, if so, is not feeling an urge to push,) and there are none of the complications noted below, the mother may be moved to the OB ward. If the baby is crowning and none of the complications noted below are found, you will have to deliver the baby. Keep in mind that this is not a pathologic process! The perineum is usually swabbed with povidone iodophor and draped with towels. Control the baby's head with your non-dominant hand. If necessary, to permit delivery of the baby, inject the midline perineum with lidocaine and perform a midline incision down to (but not into) the rectal muscle. Usually the amniotic sac will have broken; if not, open it now. Note the color and consistency of the amniotic fluid. The lambdoid suture will usually be anterior and about 30 degrees to the midline; it will turn to the AP plane and emerge. The head will turn to the coronal plane of the mother; suction out the mouth and nose once the head is out. Use a DeeLee suction trap to suction the nose and deep hypopharynx if the amniotic fluid is not clear. Check the child's neck for the umbilical cord; if it is found wrapped around the neck, pull it over the head gently. If this is not possible (too tight, too many loops, etc.), double clamp the cord and divide the cord between the clamps. Recheck the neck, as the cord may be wrapped more than once, then deliver the child expeditiously. Gentle traction toward the mother's posterior will usually deliver the anterior shoulder; if unsuccessful, try pressing over the mother's bladder to press the anterior shoulder posteriorly. If this is unsuccessful, you may be dealing with a shoulder dystocia. There are a number of options: wait for the OB, deliver the posterior shoulder and rotate the anterior shoulder posteriorly then delivering that one or one of the more destructive moves, like fracturing the anterior clavicle (a difficult maneuver at best.) Once the shoulders are out, the rest of the baby will slip out quickly; be careful, they're slick!! Keep your non-dominant hand on/under/controlling the baby's head and slide your dominant hand under and along the baby as it is expelled. Once the feet are out, rotate the baby 180 degrees into a football hold. Re-suction the nose and mouth. Double clamp the cord 7 - 10 cm. from the baby and cut between the clamps. If the child looks good, starts breathing, moving, etc., hand off the baby to nursing personnel. Make sure the baby is vigorously dried and suctioned. Keep it warm!!! If the birth is complicated by thick meconium (amniotic fluid that is green, a pea soup color [and, occasionally, consistency]), don't stimulate the baby to cry. Instead, use a 3.0 ET tube, intubate the trachea and suction it out, then stimulate the baby's breathing. Do not unclamp the mother's side of the placenta until you are certain that there is not another baby in there!! (Feel the uterus; if it is almost in the pelvis, you can be pretty sure there's only one.) Let the cord drain, collecting a clot tube for lab studies. Let the third stage of labor, delivery of the placenta, go slowly. Don't pull on the cord; just guide the placenta out as it's expelled. Inspect the placenta to be sure all of it came out. It is a generally good risk management practice to send the placenta to pathology. If mom and baby are doing well and you feel comfortable inspecting and repairing vaginal and perineal repairs, do so. It is generally permissible to let the OB/FP finish up this portion. Assuming the mother and baby are doing well/don't need resuscitation, they can be moved to the OB ward for the rest of their care. Apgar scoring is a rough estimate of the baby's immediate adaptation to extra-uterine life. They aid in determing whether the baby is taking off on its own or needs help (resuscitation.) Apgar scores should be documented at 1, 5 and 10 minutes on all newborns. If the 5 minute score is less than 7, continue scoring every 5 minutes out to 20 minutes. (However, if the child needs resuscitation, waiting to do a 1 minute score is not indicated.) Scoring system: Award 0, 1 or 2 points for each of the following and total the score. Appearance: 0=blue/pale, 1=body pink, limbs blue,2= pink. Pulse: 0=absent, 1=<100/min, 2=>100/min. Grimace: 0=no response, 1=some motion, 2=cry. Activity: 0=limp, 1=some weak motion, 2=active. Respiration: 0=none, 1=weak cry, 2=strong cry. MEDICATION Few drugs are used or needed in an uncomplicated delivery. If there is excessive bleeding, first try massaging the uterus as uterine atony is the most common cause of this complication. This is not trying to push it out the vaginal canal but involves gently squeezing/compressing the uterus to get the myofibrils to contract. This will compress the vessels perforating the uterus. If this fails, try oxytocin (Pitocin) then prostaglandin F2 (see below.) Drug Category: Oxytotics Drug Name Oxytocin (Syntocinon - Sandoz) - Indicated in postpartum hemorrhage to increase uterine myometrial tonus Adult Dose 10 - 40 U in 1 liter Lactated Ringer's, run at a rate that controls uterine bleeding. (Start wide open.) Contraindications For this use, hypersensitivity is the only contraindication. Interactions Severe hypertension when given soon after vasoconstrictors used in caudal blocks Pregnancy B - Usually safe but benefits must outweigh the risks Precautions Antidiuretic effects Drug Name Methylergonovine (Methergine - Sandoz) - Increases uterine myometrial tone. Adult Dose 0.2 mg. IM or IV, repeated every 2 - 4 hours as needed. Contraindications Hypertension, toxemia, pregnancy and hypersensitivity. Interactions Caution when used with vasoconstrictors or ergot alkaloids. Pregnancy C - Safety for use during pregnancy has not been established Precautions Hypertension FOLLOW-UP Further Inpatient Care: Admit to the OB ward. Transfer: Transfer of patients in labor is governed by a specific body of law which is too large to review here. Plese see the section on COBRA/EMTALA. When it is deemed necessary to transfer a patient in labor bacause of risks anticipated to the child, be aware that, in general, it is best to transport the child in the original container. Stabilization must be done to the best of your ability, labor should usually be arrested (e.g., terbutaline, magnesium sulfate, ritodrine, etc.) and care coordinated with the receiving facility and physician. Send the approriate people with the equipment likely to be needed by the method best suited (usually not private car). Indications for postpartum transfer are the same as any transfer: a patient whose needs exceed the capabilities or capacities of your hospital. Guidelines for effecting transfer out of your facility after partuition are similar to those governing any transfer and are outlined above. Special consideration must be given to the needs of the other patient, whether you are transferring the child or the mother. Complications: There are several items that may be felt on the initial vaginal exam, including the umbilical cord and the placenta. Umbilical cord - Have someone insert a sterile gloved hand into the vagina, up into the cervix, against the pelvic wall, with space between the index and middle fingers for the cord to pass uncompressed. This individual is to stay in this position and accompany the patient anywhere, being relieved of duty only when the operating surgeon/OB says so. Placenta previa: This may be known to the mother. It will usually be heralded by copious vaginal bleeding. DO NOT PERFORM A VAGINAL EXAM ON A PATIENT IN LABOR BLEEDING VAGINALLY. Get a stat ultrasound, a type and cross and a surgeon/OB. Stillbirth: Occasionally, despite everyone's best efforts, a child may be born without signs of life. Several topics merit remark. Phychological support for the parents is mandatory. Reserve judgement; you don't have all the facts yet. Be aware that regular grieving will occur, with all its potential for pathologic processes. If available, have chaplaincy services visit the parents. Referral to a support group is recommended. Stillbirth can be accompanied by other complications; referral to a physician skilled in the assessment and management of complications of pregnancy is indicated.